Name of Manual - Blue Cross and Blue Shield of Minnesota

Quality Improvement
Medical Record
Documentation
(continued)
Content
• Medication allergies and adverse reactions are prominently
noted in the record. If the patient has no known allergies or
history of adverse reactions, this is appropriately noted in the
record.
• Significant illnesses and medical conditions are indicated on a
problem list.
• Past medical history (for patients seen three or more times) is
easily identified and includes, as appropriate, significant family
history, serious accidents, operations and illnesses. For
children and adolescents (18 years and younger), past medical
history relates to prenatal care, birth, operations and childhood
illnesses.
• For patients 10 years and older, there is an appropriate notation
concerning the use of tobacco, alcohol and substances.
• The history and physical exam identifies appropriate subjective
and objective information pertinent to the patient’s presenting
complaints and includes medications.
Assessment and Plan
• Laboratory and other studies are ordered, as appropriate
• Assessment of each encounter reflects patient’s chief
complaint
• Treatment plans are consistent with diagnoses
Follow-up
• Encounter forms or notes have a notation, when indicated,
regarding follow-up care calls or visits. The specific time of
return is noted in weeks, months or as needed.
• Unresolved problems from previous office visits are addressed
in subsequent visits.
• If a consultation is requested, there is a note concerning this
visit in the record.
• Consultation, lab and imaging reports filed in the chart are
reviewed by the primary care physician.
• Clinically significant abnormal consultation results, lab or
imaging study results have an explicit notation in the follow-up
plans.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-15